Imaging of Carotid Arterial Diseases with Contrast-Enhanced Ultrasound (CEUS) - HD

Introduction

Hello, my name is Professor Cleaver, I'm a neurologist.
I'm the head of the interview in ultrasound center at the
Unity of Munich.
And today I would like to speak about the use
of contrast hand ultrasound in disease
of the correct artery.

The Need for Contrast-Enhanced Ultrasound

So the major question is did we really need
contrast hand ultrasound in the examination
of the coed artery?
So if we compare for example MRI
or CTA, we see with one stop shopping
the complete extent of the coed artery,
we see probably the high degree
of the ICA stenosis on the left side
and even we see the complete minimal lumen of this stenosis.
If we compare it to the MRI, we see the
ral artery stenosis, we see the stenosis
of the subc clain artery
and even we see the high degree stenosis
of the ICA on the left side.
So the question is, is there really a need?

Clinical Relevance of Carotid Artery Disease

Stroke is the third leading cause of death.
After shemic heart diseases and cancer.
We know that other exotic diseases may affect the
endocrinal vessel intracranial vessel themself.
88% of patient with fucus
or hemple trans ischemic attack have electro diseases
of the C artery, especially in the purification area.
Approximately 25 to 50% of all stroke are caused
by an unset coated plug
and about 80% of all strokes are ex amic.
Pathologies of the cord artery are an
interdisciplinary challenge.
Therefore, a reliable auto thought examination is essential
In unclear cases,
an advanced diagnosis imaging is necessary, especially
to find a solution whether standing surgery
or no therapy will the best for our patient.
Therefore, we need a new diagnostic challenge.
For my opinion, the new diagnostic challenge will be
contrast hands ultrasound.

Examination Protocol for Contrast-Enhanced Ultrasound

If we use contrast ultrasound, we need a special amount
of contrast agent depending on the system we are using.
The amount of contrast is between 1.6 to 2.4 CCC of
contrast followed by 10 CCC of seline flash.
Generally every baseline exhumation should start
with a gray scale examination
and this example we see the cord B,
we see the common cord artery, the tric cord artery,
and the intercurrent artery.
At the gray scale we don't see major pathologies.
If we now go to the color plus settings,
we see nice flow in the common cord artery, tric cord artery
with one branch here and the incurrent artery.
And if I ask my colleagues, did you see any stenosis?
They will see, okay, it was the perfect vessel
but we don't see major stenosis
so maybe we could change our mind if we know eject a little
bit of contrast agent.
So if we inject contrast agent, we see the nice filling
of the concord artery, the OC cord artery,
the inter cord artery.
And if we look at this point here, probably none
of us have seen the stenosis of the inter cord artery.
We see that the technique has
no overriding artifacts in comparison to the cutler
and we see that only the lumen
of the vessel is filled with contrast.
Generally we can have to make a decision
whether we would like to have the examination
with some background information, either code in purple
or in gray, or whether you would like
to have the examination just in the pure contrast mode.
I personally prefer the background information
so I get some background information about the
atomic structures.

Carotid Artery Stenosis

Art cortic stenosis of the proximal part
of the interocular artery are a major cause of stroke
and approximately 10 to 50% of all extre strokes
appear in the territorial of the interocular artery.
Before surgical treatment, it's important to make a clear
diagnosis whether it's a preoc stenosis
that mean a stenosis at least more than 90%
of the intercurrent artery
or whether the patient suffer from a complete occlusion
of the intercurrent artery.
If there will be a complete occlusion
of the intercurrent artery, no treatment is necessary.
Regarding the stenosis, we start
with a baseline examination in gray scale.
We see on the left side pretty good the plug on the dorsal
wall and also on the ventral wall of the inter cord artery.
We see the minimum lumen of this flow
and here is ortho technique where we could see the minimum
extent of the sno
and the complete length of the sno in comparison
to the norm diameter of the vessel
by using the BLA or BLA mode.
We see some analyzing here that mean we have got a very,
very high velocity in this area.
In comparison to the normal velocity
in the common cord artery, it is essential
to measure the maximum velocity
and if you look in our special case here in the stenosis,
we have got an RA stenotic velocity with a velocity
over 450 centimeter a second.
This mean it's a very high degree of ICA stenosis
and this patient need to be treated either by standing
or open surgery will be there any
additional information.
Now if we inject in this case additional contraline
ultrasound, you can build your own mind
and I repeat just the examination by doing this.
So we inject contrast, we see a nice filling
of the common cord artery, we see the complete extent
of stenosis, we see the post stenotic area
and this pres zoonotic area
and even we could see the contrast attack of the plaque,
which is not visible by op or podo blur.
After a couple seconds we see even
that the contrast arrived in the stenosis
and later also appear here in the ular vein.
Just the way back to the heart,
if we now magnify the image
and repeat it, just we see the complete
extent of the ule vein.
We see the complete extent
of the intercurrent artery stenosis without artifact,
we could detect slow
and fast flow advance without overriding artifacts
and if we magnify the image, we see some bubbles inside just
as a sign that we have got some room in this kind of plug

Distinguishing Pseudo-Occlusion from Complete Occlusion

In this case, this patient already undergo a CT examination
and in the CT report they said it seems
to be this patient has got a complete occlusion of the ICA.
Unfortunately, this patient developed several small strokes,
therefore we had to have
to find out whether the still minimum flow
and the interate RRP or or it will be a complete occlusion.
If we look at the grade scale,
we could not see a major flow here in
the intercurrent artery.
There's a flow in the concord artery.
So now I just skip to the cardio plus settings.
Therefore we see the nice filling of the concord artery
and the question is are these red dots here some artifacts
or is this real flow inside this mean?
Is this now a pseudo occlusion
or a complete occlusion which have got a major effect on the
treatment of this patient?
The next step we just inject a little bit contrast.
The first one we will seen is the exon cord artery,
the common cord artery
and here we see the complete extent of the pseudo occlusion
of the internal cord artery.
And the question, how long is the pseudo occlusion is also
very easy to answer.
We just go to the next slide
and we see the complete extent of the pseudo occlusion.
This is the reason why the patient developed couple strokes
in the past and this patient have
to have a treatment in this disease.
Also, this patient, there was a question whether this
patient suffer from OC complete occlusion of the ICA
or not and gray scale seems to be some HA organic
plugs inside in this vessel.
By using the color blood mode we see just the first branch
of the external cord artery,
but we could not detect even we have got a good velocity
any flow in the inter cord artery in this patient.
Now maybe power dola is more sensitive
as we know in the past has more likely
to detect any flow in the inter cord artery,
but even in this case we could not see any flow inside here.
So there seems to be a suspicion of occlusion
of the inter corded artery.
Additional we inject contrast, we see the complete filling
of the concord artery, we see the ex cord artery,
the first branch here,
but we see only here a minimum lumen
of the inter cord artery.
But after this minimum lumen,
the complete inter cord artery is occluded.
So this means this patient needed not to be treated either
by standing or open surgery.

Post-Treatment Follow-Up

Patient who undergo a treatment either standing
or current endarterectomy have
to have a follow-up examination.
So traditional ectomy has to be in the procedure of choice
for sexual symptomatic or asymptomatic patients.
Nowadays even there's option that the patient could go under
current artery stenting,
Especially if a patient is a high risk patient
because the patient has got degradation or high
or lower cervical lesion
or have some problems with cardiopulmonary diseases,
then there will be an option to undergo standing
of the correct artery.
But both mes have some risks that will be osis either on
an ectomy or standing of the correct artery.
This patient is a follow-up examination of the CO
and a we see in the gray scale the bull,
we see the patch plastic here just adjacent to the bull
and the question is,
will patient suffers still from a wisdom noses
or if everything is right?
It seems to be very difficult in gray scale
to answer this question.
Therefore we just change the setting and look at the LAR
and powder plus settings.
This is the bulb that's exon cord artery, inter cord artery,
common cord artery.
It seems to be some soft plugs just
adjacent to the correct wall.
Maybe powder blood is a little bit more helpful,
but even here we have some problems
that we could not detect the complete flow volume
in the internal cord artery.
Again, we inject a little bit contrast to see
what about these vessel that take a couple seconds.
Then we see the common curl artery, the exon cord artery,
the intercurrent artery
and if we compare this jaw to the cardo
and powder setting, we have got a nice fitting
of the complete bulb
and we can see the patient has some soft plugs here,
but safe patient doesn't suffer from any stenosis
of the intercurrent artery in this case.

Post-Surgical Hematoma Evaluation

After open surgery, the patient even could develop hematoma.
This patient has got a hematoma just adjacent to the
common cord RV
because he undergo open surgery of the cord RV
and the question is,
is it still now an active bleeding or not?
So we have to find out whether the patient need
to have a treatment or not.
If we look at this axial plane,
we see pretty good the complete extent of the hematoma.
The hematoma already compressed a little bit the ule vein
by using the poly plaing we see the flow in the concord
artery, but we couldn't detect any flow in the hematoma.
Does it mean that there is no active bleeding if we couldn't
detect any flow by a power doppler in the hematoma?
Probably if we have to rule out this
and inject in a little bit contrast agent,
So it takes some seconds when the contrast arrived.
Here is a nice thing of the concord artery.
Here we see hematoma, the hematoma still appear in black
so it doesn't show any kind uptake.
So it seems to be that there is no active bleeding.
Here we see the ular vein
and of course we have got an examination time up
to three minutes after a single injection of contrast.
We take our time and just change the
view and look a little bit later.
That's after one minute we see the hematoma is still black,
so no active bleeding after one
and a half minutes, no change, no active bleeding.
So this patient have to have no treatment
because we didn't see any active bleeding
after current surgery.

Stent Follow-Up

Patient who undergo standing
of the intercurrent artery even have some problems
because they have to have a follow
up for the end of their life.
In grade scale we see very nice the stand placed in the
intercurrent artery.
But the question is, is there any instance s
probably it's very difficult to answer this question
by a fundamental gray scale examination.
So we just use the power doppler and color plus setting.
So we see a nice filling of the stand in this both modes.
It seems to be no measure the noses,
but of course we have
to measure the maximum velocity in stent
to detect an stenosis.
If we look at the maximum velocity in the stent,
we have got a velocity between two meters
or two and a half meters.
There seems to be not a normal velocity,
therefore there's suspicion of an instant stenosis.
But by using the BLA
or powder ings, we couldn't detect any instant stenosis.
Again, we inject a little bit contrast,
we see have the same plane
and now we see purifying that in this part
of the stand there is no ous uptake seems
to be an instant notice
and if you just shift the probe in anxi plane
and repeats the examination, we see that half
of the lumen doesn't show any kind of uptake.
And if we magnify the image
and just scan it again,
we see again the complete extent of the stenosis.
In this case we see pretty fine that about 50%
of the stent has got the stenosis
inside called an instant stenosis without any uptake.
And if we compare those now to Cal Dolar
or powder doppler, it's much easier
to detect this instant S noses without the overarching
artifacts in this other technique.

Carotid Artery Dissection

Dissection of the cervical segment of the cord artery
or ral artery are very uncommon.
The incident is about one to three cases or 1,100,000 cases.
15 to 20%
of all CE infarction in young adults are cause
to the dissect of these vessels.
Cervical dissection are usually classified
as either traumatic or spontaneously.
Therefore we have to answer whether there's still a blood
flow in the falls and in the true lumen.
And what about the risk of thrombosis?
Starting again with a gray examination, it seems
to be here a flap just adjacent to the concrete artery wall.
But the question is, is this not just a flap
or is this maybe a collapsed uh, false lumen?
Again, we shift to the LAR and power plus settings
and seems to be a little bit flow here
and also it seems to be just a flap in the middle
of the vessel.
The question is, is this now an artifact
or is it really a dissection?
Again, we have to inject a little bit contrast
and repeat the examination that we see.
Pretty fine that there is a flap just
in the middle of the vessel.
And again also here is a small lumen of the dissection
and if you just shift now the probe in the exit plane,
we see pretty good the complete extent of the dissection,
the true lumen, the fourth lumen
and the flap which enter the middle of this vessel.

Rare Cases

Arteriovenous Fistula

Also, I would like to show you some rare cases like fistula
of the ucle vein
and the internal cord artery and a rhythm
and also I would like to speak about called body tumors.
This old woman, Uh, was lying on care unit.
They tried to place a central line
catheter in the ular vein.
Unfortunately the patient developed some problem
with the heart afterwards, so there were also suspicion
of a fist alert between the ular vein
and the common cord artery.
If we look very carefully at the gray scale, there seems
to be a connection between the ular vein
and the cordal artery just in this area here.
And if you now go to the PL setting, we see a lot
of analyzing as an indirect sign of a fistula just
between the common cord artery
and the ular vein.
If we now inject bit contrast, we see the complete extent
of the fistula tunnel without artifacts,
without already artifacts.
And we also see the angle of the central line,
which was was not perfect in this case.

Pseudoaneurysm

This patient also undergo central line placement.
Afterwards there was a suspicion of hematoma,
so there is just hematoma just between the ular vein here
and the concord artery.
If we look in the CarPros setting, it seems to be
that there seems to be some flow in this hematoma,
so it is now a pseudo aneurysm or just hematoma
or there's a fistula between the two vessels.
So if we inject a little bit contrast,
we see pretty nice filling of the concord artery
and we see that these hematoma show up contrast uptake
as an indirect sign of thes aneurysm after intervention.
And we see the complete extent of the stool aneurysm here.
There is not a direct connection to the ular vein
if we have the same examination just in the longhand plane.
We see here is the neck of the pseu aneurysm
and here is the pseu aneurysm which shows the uptake
of the bubbles in this area.
The axi plane, again,
there's the pseu aneurysm which compress also a little bit
the ular vein.
Now of course the pseu aneurysm have
to be treated afterwards.

Aneurysm

An rhythm of the external intercurrent artery are rare.
So if we look at this case, it seems to be uh, an rhythm
of the intercurrent artery.
This is a concord artery, this is external cord artery.
Of course this aneurysm has to be treated.
This aneurysm has got a diameter about two centimeters.
The quest th from the surgeon is,
are there thrombotic changes in the aneurysm
and what about the complete extent of this aneurysm?
So if we try to answer the question,
we see the same examination in the color plus setting
and even in the poly plus setting, there seems
to be some thrombotic changes in this area or here
and now I will like to repeat the examination just
by using contrast Anand.
We see the complete extent of this aneurysm
and if we skip the probe in the Axi plane,
we see these huge thrombotic changes in the aneurysm
and we can say this aneurysm had at least a diameter
or about two centimeters in this direction and two
and a half centimeter in this direction.

Carotid Body Tumor

This young man was sent to us
because from his house doctor there was suspicion
of a aneurysm of the common cord artery.
So if we start the examination in the gray scale,
there seems to be an Hagan mass just adjacent to the
common cord artery,
either thrombotic mass or something else.
If we now use the cardio blood setting,
we could see very fast.
There seems to be some vessels in this
mass here just adjacent to the common cord artery.
Often we find color body tumors just in the uh, purification
of the correct artery
or just adjacent to the common cord artery.
So it seems to be a body tumor
of the cord artery in this case,
if it'll be a called a body tumor,
this tumor will have a very, very fast
and very strong uptake, very similar like the
common cord artery.
So repeats examination there, the common cord artery
and see this tumor has the same kind of uptake
as ity in this vessel
and we see pretty fine the complete extent of this
body tumor which have to be treated afterwards,
just the ification.
And you see part
of this tumor also entered already the bifurcation of the
cord artery as the syn here in the middle
of the image the ification.

Plaque Neovascularization

My last topic will be ization of plugs.
The most widely except predictor for stroke is a degree
of cord stenosis.
However other additional imaging features, uh,
become recognized as significant factors.
Plug alteration has been long sought
to play a major role in the ology of strokes
of the internal cord artery diseases.
That was already done.
A couple of studies by MRI CT A, which detected plugs
and try to quantification these plugs.
But due to the advantage
with a very high temporal resolution
and S SPA solution, we can also use the contrast
and ultrasound examination to look
for neovascularization of plugs.
If we start again with the iCal examination
and poly examination,
we see the complete exten plug here on the concord artery.
By using the powder plug examination,
we could not see major flow inside.
So the question is does this plug show any contra yes or no?
So we inject contrast,
we see the con uptake in the concord artery
and this plug is complete plaque.
So it seems to be no con uptake
and even if we look in the later phase of two minutes,
there seems to be no uptake.
This means not every plug have to have ous uptake,
even if it's a huge soft plug.
This is the next patient also
with some soft plugs either on the dorsal wall
of the concord artery
but also on the ventral part of the concord artery.
Again, we look for the vascularization in the
OR powder blood mode.
Both technique could not show any flow
inside of these plugs.
And the question is whether we have more success now
with this patient to see whether the plug show any con take.
Again, we inject contrast.
We see the complete extent here seems to be also stenosis.
And if we look very carefully, we see a couple
of bubbles appear here in this area
and over time we see more and more bubbles appear here.
But also in this area a couple of bubbles appear.
Sometimes it's very difficult
to see the complete extent of the bubble uptake.
Therefore I recommend just to store this image
and look again at the summary of the image.
So if we start, we see its complete plaque
and over time there the bubble appear here, bubbles appear
so they cannot uptake over time on the ventral part
and even a little bit later also on the dorsal part of the
common cord artery.
If we look at the concord artery in this patient,
it seems a very complex situation.
It seems to be that this patient has got
some ulceration here.
The question is, is the real ulceration
or a high degree of stenosis probably where we have
to rule out to find to use contrast
and ultrasound in the setting.
So we inject a bit. Contrast seems to be here in the middle,
a high degree of S noses
and even here this patient has some ulceration
there and there.
If we just look again, there's the ulceration
and there's the ulceration.
And if we now skip the probe in a different long term plane,
we see complete ulceration here, that ulceration and here
and here, here this patient suffer from a high degree of the
uh, artery stenosis.
We just look at the pure contrast mode.
We get similar results.
The complete extent of the iic aosis
and the bolts all goes here on the ventral part
and even on the dorsal part of the concurrent artery.
My final case will be this patient
which suffer from a high degree of stenosis.
We see the lighting here.
The question is does this plug already show
some contrast uptake?
Yes or not by using the color plug we couldn't see any flow
inside the kind of mixed plug here seems
to be some calcification
and here seems to be some soft plugs again,
repeats examination.
So with the complete extent of the S noses here
and of course we see here a couple
of bubbles appear either from the vessel
and also a couple of bubbles appear which was feeding from
the wall of the common cord artery.

Guidelines and Indications for Contrast-Enhanced Ultrasound

So in the guidelines from the, which
was just published in 2011, there are some indication
for the use of contra and ultrasound
and disease of the current riv.
For example, if the patient suffer from a stenosis,
it's very difficult to see then the use of contrast
and could improve it.
Patient after standing have some problems sometimes
to see the complete extent of the lumen.
Even in this case the use of conal ultrasound
will be helpful tool
to see whether the patients perform an instant stenosis.
If the patient has got dissection.
Sometimes it's difficult to say whether the false lumen show
any flow anymore and even here in this case,
if we inject contrast we could make clear diagnosis
If there are complications
after vascular interventions, either fistula
or huge hematoma, the use of contrast could
be very helpful for the planning
of the follow-up of this patient.
Whether the patient need to have a treatment, for example,
if it's an active bleeding or if it's a fistula.
And finally we also sh could see that a couple
of plugs show chronic uptake
and in previous study we have
to find out whether there will be a close correlation be
between the risk of strokes and the plaque.

Advantages of Contrast-Enhanced Ultrasound over Color Doppler

Take just one comparison
between the ColorPlus settings
and the contrast resounding settings
which would be the advantage.
So we just start with the first topic. Analyzing.
Sometimes if we have got a high degree of s nose,
there seems to be sometimes ais.
If we compare this to contrast, resound, there's no izing
the single drop out.
If the scanning angle is not perfect, Bacalla in contrast,
resound, it's independent.
We have got a very high spatial solution
and contrast there's a low spatial solution.
By using the ColorPlus settings,
by using the contrast sensor setting, we could detect slow
and fast flow advance.
By using the ColorPlus we have make the decision whether we
focus on high flow or slow forward.
For the complete extent of stenosis,
there will be no blooming artifact in comparison
to blooming artifact by color blur, it's difficult
to see the flow direction sometimes by using contrast
of course there will be some advantage
by using the ColorBlast settings.
If you just look how much parameter we have to change,
sometimes based in contrast we just have to push one button
and we can start in color.
Pla it seems to be somewhat difficult
and also we have no limitation
with the wall filter like we have in the ColorBlast settings
in comparison to the science settings.

Conclusion

So I hope you have learned a lot of new topics
and thanks for your attention.